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DiCoT: an accessible method for understanding technology use in healthcare

Key points

  • Distributed Cognition is a theory about how our mental processes work that extends cognition from the thoughts in our head to include the way we use objects in the world to represent information too. We have made it easier to apply Distributed Cognition to understand the way people work in healthcare.
  • In particular, we have developed a method called DiCoT that supports analysts studying healthcare contexts in using Distributed Cognition to understand those contexts.
  • We have shown that DiCoT can give valuable insights in a variety of healthcare contexts, from hospital wards to patient's homes, and for a variety of different devices including infusion pumps, blood glucose meters and haemodialysis machines.

Background
People don't often pay much attention to how things get done: what matters is the outcome. How things get done is important, however, when trying to understand how people fit technologies into their work and their lives. It is also important when trying to understand how to improve the design of those technologies. A systematic approach to observing and interviewing is needed by field workers to make it easier to know what data to gather (and how), and how to analyse it and report findings. We have developed a methodology called DiCoT (Distributed Cognition for Teamwork) to do this.

Distributed Cognition is a theory about how our mental processes work that focuses on how information is transferred and transformed as it moves between different people, places, tools and representations. It has been widely used in work settings such as flight decks and control rooms, that are relatively well structured. The main use has been for reasoning about how people share and become aware of information. It has been gaining prominence in healthcare, where there is a growing recognition of its strengths. It provides a valuable way of thinking about clinical team work that involves both people and technology. Many mistakes occurring in healthcare have been attributed to 'system failure' and so involve this team work breaking down in some way. We need better ways to deepen our understanding of what works and of where things go wrong to reduce risks and avoid mistakes.

Distributed Cognition has been criticised as being hard to apply because there is little support to help researchers use it. Our approach to solve this problem has been to develop DiCoT. It focuses particularly on how technology is used by teams of people, tools and artefacts. It involves first doing observations and interviews, then building models to describe the data. Finally, a set of Distributed Cognition principles are applied to identify what works well and what could be improved.

Applying DiCoT
DiCoT had not previously been tested in situations such as hospital wards or people's homes. It was not clear whether it could sensibly be applied in such settings, and whether it would deliver valuable insights. We have shown that it can.

We have applied it in an intensive care unit (ICU), two different hospital wards (haematology and oncology), a medical equipment library, an oncology day care unit, an operating theatre, and in people's homes. In each case it has delivered valuable insights.

The work included testing how easy DiCoT is to learn and apply, and extending it as needed to support reasoning about more aspects of team working with technology. In particular, we extended DiCoT so that it could reveal issues and identify good design and practices that matter in these different settings.

This work is gaining visibility and recognition. For example, Rajkomar's work applying DiCoT in an intensive care unit has been recognised by the Faculty of 1000, a group of leading experts who recommend articles they consider to be most important across all areas of biology and medicine. Rajkomar has now moved to a job with a specific brief to apply DiCoT in commercial contexts. Furniss' work on glucometer use was nominated for the best paper award in the journal, Applied Ergonomics, and included in the annual Virtual Special Issue of papers that 'best demonstrate the comprehensive application of ergonomics in a clear and interesting fashion'. Other teams have also now started to apply DiCoT independently.

Publications
Berndt, E., Furniss, D., & Blandford, A. (2014). Learning Contextual Inquiry and Distributed Cognition: a case study on technology use in anaesthesia. Cognition, Technology and Work. 1-19.

Furniss, D., Blandford, A., Mayer, A., Rajkomar, A. & Vincent, C. (2011). The visible and the invisible: Distributed Cognition for medical devices. Proc. EICS4Med.

Furniss, D., Blandford, A. & Mayer, A. (2011). Unremarkable errors: Low-level disturbances in infusion pump use. Proc. British HCI.

Furniss, D., Masci, P., Curzon, P., Mayer, A. & Blandford, A. (2015). Exploring Medical Device Design and Use Through Layers of Distributed Cognition: How a glucometer is coupled with its context. Journal of Biomedical Informatics. 53. 330-341.

Furniss, D., Masci, P., Curzon, P., Mayer, A. & Blandford, A. (2014) 7 Themes for guiding situated ergonomic assessments of medical devices: A case study of an inpatient glucometer. Applied Ergonomics. 45. 1668-1677. Nominated for Best Paper Award 2014 (one of 12 finalists).

Masci, P., Curzon, P., Blandford, A. & Furniss, D. (2011). Modelling Distributed Cognition Systems in PVS. Fourth International Workshop on Formal Methods for Interactive Systems (FMIS 2011).

Masci, P., Curzon, P., Furniss, D. & Blandford, A. (2012). Using PVS to Support the Analysis of Distributed Cognition Systems. Innovations in Systems and Software Engineering.

Rajkomar, A., & Blandford, A. (2012). Understanding infusion administration in the ICU through Distributed Cognition. Journal of biomedical informatics, 45(3), 580-590. Recommended by Faculty of 1000 (F1000Prime)

Werth, J. & Furniss, D. (2012). Medical Equipment Library Design: Revealing Issues and Best Practice Using DiCoT. Proc. International Health Informatics Symposium (IHI 2012), Miami, Florida, Jan 28-30.

Key People
Erik Berndt, Ann Blandford, Paul Curzon, Dominic Furniss, Paolo Masci, Astrid Mayer, Atish Rajkomar